Provider Demographics
NPI:1306809819
Name:KELTY, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:KELTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:SUITE 530
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1300
Practice Address - Country:US
Practice Address - Phone:502-637-3311
Practice Address - Fax:502-637-3168
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27932208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64279326Medicaid
KY0386601Medicare PIN
KY64279326Medicaid
KY0983205Medicare PIN
IN179060CMedicare PIN
KY0395201Medicare PIN